Intraoperative control by somatosensory evoked potentials in the treatment of cervical myeloradiculopathy. Results in 210 cases

Somatosensory evoked potentials (SEPs) were used for continuous monitoring of 210 patients during anterior surgery for cervical myeloradiculopathy, to test how effectively they help avoid irreversible neurological damage during surgery. The pathologies differed in severity and were treated by diskectomy or by extended corporectomy using the Senegas technique. Intraoperative SEP changes were recorded in 84 patients (40%); in 13 (6.2%) of these, changes in SEP amplitude and latency were caused by mechanical stress. SEPs revealed transient episodes of regional ischaemia or neurophysiological anomalies during anaesthesia (mainly hypotension) in 27 patients (12.8%). The traces detected incipient and potentially dangerous mechanical pressure on, or metabolic anomalies of, the spinal cord during manipulation and placement procedures of spinal fixation devices. They were particularly sensitive indicators of ischaemia; one of the most common causes of irreversible injury. The traces of 44 patients (21.0%) improved markedly during surgery. There were no false-negatives in this series and, thanks to the fact that SEPs gave immediate warnings of incipient ischaemia to the surgical team, we had no case of irreversible medullary or nerve-root deficit.

Comparison Between the Japanese Orthopaedic Association (JOA) Score and Patient-Reported JOA (PRO-JOA) Score to Evaluate Surgical Outcomes of Degenerative Cervical Myelopathy

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

To investigate whether the Japanese Orthopaedic Association (JOA) score can be used for patients with degenerative cervical myelopathy as a patient-reported outcome (PRO) through the JOA written questionnaire.

METHODS

A total of 75 patients who underwent posterior decompression surgery for degenerative cervical myelopathy were reviewed. Patients responded to questionnaires including PRO-JOA, EuroQOL-5D, Neck Disability Index, and Short Form-12 preoperatively and at >12 months postoperatively. Spearman's rho and Bland-Altman analyses were used to investigate the correlations.

RESULTS

Preoperative JOA and PRO-JOA scores were 10.8 and 10.6, respectively, with Spearman's rho of 0.74. Similarly, postoperative JOA and PRO-JOA scores were 13.3 and 12.9, respectively, with Spearman's rho of 0.68. However, the recovery rates for JOA and PRO-JOA scores were 42% and 27%, respectively, with Spearman's rho of 0.45. Compared with other PROs, JOA and PRO-JOA scores were moderately correlated. The minimum clinically important difference was 2.5 for JOA score, 3.0 for PRO-JOA score, 42% for JOA recovery rate, and 33% for PRO-JOA recovery rate. Bland-Altman analyses revealed that limits of agreement were -4.3 to 4.7, -3.4 to 4.3, and -75% to 106% for the preoperative score, postoperative score, and recovery rate, respectively.

CONCLUSION

PRO-JOA score can also be used as a disease-specific scoring measure instead of JOA score. However, although both measures demonstrate a similar trend as a group analysis, PRO-JOA and JOA scores should be regarded as different outcomes.

Surgical Outcome of Laminoplasty for Cervical Spondylotic Myelopathy in an Elderly Population - Potentiality for Effective Early Surgical Intervention: A Meta-analysis

A systematic review and meta-analysis was conducted to determine differences in surgical outcomes of laminoplasty for cervical spondylotic myelopathy (CSM) between elderly and non-elderly patients. PubMed and Google Scholar searches were performed using several key words and phrases related to cervical laminoplasty in elderly populations. Included studies were written in English, addressed laminoplasty for cervical spondylotic myelopathy, and evaluated outcomes of the treatment. Statistical analysis was performed using a random-effect model. The heterogeneity of the studies was assessed using Cochran's Q statistic and I² statistic, and a funnel plot was constructed to evaluate publication bias. The search initially identified 255 articles on this topic. Nine clinical studies that met all inclusion criteria were included in the meta-analysis. A total of 1817 patients in these studies underwent cervical laminoplasty. Elderly patients had lower preoperative and postoperative Japanese Orthopedic Association (JOA) scores, and lower recovery rates based on JOA scores. Shorter operation times and reductions in intraoperative blood loss were found in the elderly group compared to the non-elderly group. The incidence of C5 palsy was not different between these groups. We here report the differences in surgical outcomes of laminoplasty for CSM through systematic review and meta-analysis. This report found poor surgical outcomes and lower preoperative JOA scores in elderly patients. Therefore, early surgical intervention may be recommended in elderly patients with CSM.

Multilevel decompressive laminectomy and transpedicular instrumented fusion for cervical spondylotic radiculopathy and myelopathy: A minimum follow-up of 3 years

Objective:

Cervical laminectomies with transpedicular insertion technique is known to be a biomechanically stronger method in cervical pathologies. However, its frequency of use is low in the routine practice, as the pedicle is thin and risk of neurovascular damage is high. In this study, we emphasize the results of cervical laminectomies with transpedicular fixation using fluoroscopy in degenerative cervical spine disorder.

Materials and Methods:

Postoperative malposition of the transpedicular screws of the 70 pedicles of the 10 patients we operated due to degenerative stenosis in the cervical region, were investigated. Fixation was performed between C3 and C7, and we used resected lamina bone chips for fusion. Clinical indicators included age, gender, neurologic status, surgical indication, and number of levels stabilized. Dominant vertebral artery of all the patients was evaluated with Doppler ultrasonography. Preoperative and postoperative Nurick grade of each patient was documented.

Results:

No patients experienced neurovascular injury as a result of pedicle screw placement. Two patients had screw malposition, which did not require reoperation due to minor breaking. Most patients had 32-mm screws placed. Postoperative computed tomography scanning showed no compromise of the foramen transversarium. A total of 70 pedicle screws were placed. Good bony fusion was observed in all patients. At follow-up, 9/10 (90%) patients had improved in their Nurick grades. The cases were followed-up for an average of 35.7 months (30–37 months).

Conclusions:

Use of the cervical pedicular fixation (CPF) provides a very strong three-column stabilization but also carries vascular injury without nerve damage. Laminectomies technique may reduce the risk of malposition due to visualization of the spinal canal. CPF can be performed in a one-stage posterior procedure. This technique yielded good fusion rate without complications and can be considered as a good alternative compared other techniques.

High cord signals on magnetic resonance and other factors predict poor outcomes of cervical spine surgery: A review

Background:

High cord signals (HCS) on preoperative/postoperative T1, T1 gadolinium-diethylenetriaminepentaacetic acid (Gd-DTPA), and T2 magnetic resonance (MR) studies, postoperative failure of HCS to regress and/or cord re-expansion, and a triangular cord configuration are poor prognostic factors for surgical patients with cervical spondylotic myelopathy (CSM).

Methods:

Here, we reviewed the negative prognostic import of high Grades/Types and more extensive locations of preoperative/postoperative HCS on T1, T1 Gd-DTPA, and T2 MR studies in surgical patients with CSM. Additional predictors of poor operative outcomes included postoperative failure of HCS to regress, cord re-expansion at the site of a HCS, and the triangular vs. teardrop or boomerang cord configuration. The Types/Grades of HCS on MR follow:Type/Grade 0 – no/absent signal changes; Type/Grade 1 – mild/light/fuzzy/obscure/low cord signal (LCS) changes; Type/Grade 2 – sharp/intense/well-defined HCS; and Type/Grade 3 – mixed/HCS. The definitions of location/extent of LCS/HCS were: focal (1 level), multifocal (with skip areas), and multisegmental (continuous over >1 segment), while cord configuration was categorized as triangular, teardrop, or boomerang.

Results:

On MR studies, preoperative/postoperative Types/Grades 0–1 changes correlated with better prognoses (e.g., improved Japanese Orthopedic Association (JOA) scores or Nurick Grades), while Types/Grades 2–3 correlated with poorer outcomes. Multiple poor prognostic indicators also included; failure of postoperative HCS on MR to regress (particularly if multisegmental), postoperative cord re-expansion at the site of a prior HCS, and triangular cord configuration.

Conclusions:

Grade/Types 2–3 HCS on T1, T1 Gd-DTPA, and T2-weighted MR images on preoperative/postoperative MR studies, failure of HCS to regress (multisegmental), cord re-expansion at the site of a prior HCS, and a triangular cord configuration (atrophy) all contributed to poorer outcomes for CSM surgery.

Commentary on article: Laminoplasty versus laminectomy and fusion for multilevel cervical myelopathy: A meta-analysis of clinical and radiological outcomes by Chang-Hyun Lee et al

Background:

This is a commentary on the article laminoplasty versus laminectomy and fusion (LF) for multilevel cervical myelopathy: A meta-analysis of clinical and radiological outcomes by Chang-Hyun Lee et al. Here, the authors utilized seven studies to compare the efficacy of cervical expansive laminoplasty (EL) versus laminectomy and fusion (LF) to address three or more level multilevel cervical spondylotic myelopathy (CSM). Both procedures led to similar degrees of neurological recovery and short-term loss of lordosis, but found that LF led to more favorable long-term results.

Methods:

For patients with three or more level CSM, laminectomy followed by an instrumented fusion (LF) has major advantages; open bilateral decompression of the nerve roots, while minimizing the risk of inadvertent injury to the cord, and the fusion's maintenance of lordosis.

Results:

Some would argue that inadvertent cord/root injury is greater utilizing any of the EL techniques; e.g., unilateral, bilateral, or spinous process splitting techniques. In short, why risk cord/root injury by manipulating the compressive posterior/posterolateral elements, which are already threatening neural function.

Conclusion:

Although the results of EL versus LF appeared comparable in the short-term in these seven articles, LF resulted in better long-term outcomes. Some would also argue that LF, utilizing an open approach offers safer bilateral neural exposure and decompression.

Evaluation of Postoperative Kyphotic Changes in Patients Who Underwent Cervical Laminectomy

BACKGROUND

The stenosis of the cervical canal due to spondylotic changes is one of the common causes of spinal cord compression. Without adequate treatment, it results in progressive neurological deterioration. However, despite the wide acceptance of newer techniques, such as laminoplasty and laminectomy with fusion, in most situations, especially in resource-constraint situations, the role of laminectomy alone is pertinent. The following study reviews the effectiveness and safety of laminectomy alone in patients with cervical spondylotic myelopathy.

METHODS

A retrospective cohort study was conducted at Par Private Hospital, Erbil, including 46 patients diagnosed with cervical canal stenosis. All patients underwent laminectomy without fusion or laminoplasty, and postoperative outcomes were assessed using the modified Japanese Orthopaedic Association (mJOA) score, Neck Disability Index (NDI), and radiographic evaluations of cervical alignment. The relationship between preoperative and postoperative cervical alignment, kyphosis progression, and clinical outcomes was analyzed.

RESULTS

Most patients showed significant neurological improvement in accordance with the improvement of scores of both mJOA and NDI. Among them, radiographic kyphosis progression occurred in 40% of patients, which was not associated with clinical deterioration. This showed a remarkable correlation between preoperative cervical alignment and postoperative outcomes, with R² = 0.733 and p < 0.001. No major complications like C5 palsy or wound infection were recorded throughout the follow-up period.

CONCLUSION

Laminectomy alone constitutes a proper and safe surgical alternative for cervical canal stenosis, especially in resource-poor countries. Although kyphosis progression occurred in some cases, there was no clinical impairment. Careful selection of patients by preoperative alignment is important for favorable outcomes. Comparing laminectomy alone with other techniques in longer follow-up will provide the final result in larger, multi-institutional groups.

Cervical spondylotic myelopathy presenting as a "pancake enhancement" on MRI of the spinal cord: A case report and review of literature

Spondylotic myelopathy involves chronic spinal cord compression from degenerative spine changes presenting a myriad of neurological and pain symptoms. We report a case of cervical myelopathy with transverse pancake-like gadolinium enhancement seen on MRI in a 42-year-old gentleman with progressive bilateral upper extremity numbness, tingling, and impaired gait.

Syringomyelia resolution after anterior cervical discectomy: A case report and literature review

Background:

Syringomyelia is rarely associated with cervical disc herniations and/or spinal stenosis.

Case Description:

A 62-year-old male presented with a 4-month history of right brachial pain and hyposensitivity in the C5 distribution. The cervical magnetic resonance (MR) imaging scan revealed a C5–C6 right anterolateral disc herniation with syringomyelia extending from C5–C6 to T1. Following a C5–C6 anterior cervical discectomy and fusion (ACDF), the patient’s symptoms resolved. The 3-month postoperative MR documented total resolution of the syrinx. Notably, due to residual neuropathic pain, the patient required a subdural spinal cord stimulator which was placed without any complications.

Conclusion:

Syringomyelia rarely occurs in conjunction with cervical disc disease and stenosis, and even more infrequently resolves following an ACDF. Future research should focus on the etiology of syrinx formation in these patients and should explore their response to various treatment modalities.

An Uncommon Presentation of Cervical Myelopathy

Cervical myelopathy is a compressive spinal cord disease usually affecting individuals 55 and older. Involvement of C5-C7 is typical and classically presents with hand clumsiness, wide-based gait, and paresis. We present the case of a 38-year-old man with a pertinent history of a previous motor vehicle accident who presented to the emergency department for progressive numbness, weakness, and severe spasms in both lower extremities, and eventually developed bowel and bladder incontinence. Lumbar magnetic resonance imaging (MRI) showed moderate L3-L4/L5-S1 degenerative spinal changes; however, cervical MRI demonstrated severe C6-C7 spinal stenosis. The patient did not present with any upper extremity neurological changes. Given the relatively mild changes in the lumbar spine, the patient was concluded to have lower extremity and autonomic neurological issues due to severe cervical spinal stenosis. In this report, we present a relatively common case of cervical myelopathy and myelomalacia in a patient unusually presenting with no upper extremity signs and only lower extremity signs of progressive bilateral leg weakness and neurogenic urinary incontinence. This case emphasizes the importance of considering cervical spine workup in addition to thoracic and lumbar spine and conducting a comprehensive clinical neurological examination in the setting of lower extremity symptoms with progressive bilateral leg weakness and urinary incontinence.

Inclusion body myositis in an older patient following a fall

After experiencing a fall, an 82-year-old woman developed progressive loss of lower limb strength and was diagnosed with inclusion body myositis. Although falls and muscle weakness are often regarded as consequences of aging, inclusion body myositis should be considered in a patient with a history of multiple falls.

Cervical Pilocytic Astrocytoma Mimicking Spondylotic Myelopathy: A Case Report and Literature Review

Spinal cord pilocytic astrocytoma (PA) is a rare, low-grade tumor in adults, typically presenting with a cystic component. Correct diagnosis is crucial, as gross total resection may improve survival rates. We report the case of a 44-year-old patient with chronic neck and arm pain, along with hypoesthesia on the left side, initially suspected of having myelitis based on MRI findings. Surgical exploration enabled near-complete resection, and histopathology confirmed the diagnosis of PA. This case highlights the importance of considering PA in the differential diagnosis of inflammatory and degenerative spinal cord disorders and suggests that further investigation is needed into its treatment and potential recurrence.